Nicardipine and adenosine "flush cocktail" to prevent no-reflow during rotational atherectomy.
BACKGROUND
Rotational atherectomy (RA) has a unique mechanism of action-it utilizes plaque abrasion with microparticle embolization in order to achieve luminal enlargement. This microscopic atheroembolic debris can lead to platelet activation, with vasoconstriction and/or mechanical obstruction of distal coronary resistance vessels, leading to no-reflow and myocardial necrosis.


OBJECTIVE
We developed a prospective registry to evaluate the efficacy of the prophylactic administration of intracoronary nicardipine and adenosine within the RA "flush cocktail" as a method of preventing no-reflow and non-Q-wave myocardial infarction (MI) in patients treated with RA in their native coronary arteries.


METHODS
One hundred seventy-six consecutive patients (204 lesions; mean age, 66+/-12 years) were treated with a flush cocktail containing nicardipine (10 microg/ml), adenosine (5 microg/ml), nitroglycerin (10 microg/ml), and unfractionated heparin (1 IU/ml) during RA. The primary study end points were postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow score and non-Q-wave MI, as determined by creatine phosphokinase (CPK) and creatine phosphokinase-MB (CPK-MB) levels. Secondary end points included baseline and acute final minimum lumen diameters, and percent diameter stenosis.


RESULTS
TIMI flow scores were analyzable in 155 of 176 patients (88%), and in 181 of 204 treated vessels/lesions (88.7%). As compared to baseline, the final TIMI score worsened in 4 patients (2%), was unchanged in 121 patients (78%), and improved in 30 patients (19%). One hundred fifty of 155 patients (96.7%), and 175 of 181 treated vessels (96.6%) had TIMI 3 flow at the completion of the procedure. Excluding those patients with elevated baseline CPK values of >190 IU/l (n=7), only 5 of 176 (2.8%) patients had CPK-MB values more than three times the upper limit of normal at 12-18 h postprocedure. There were no in-hospital Q-wave MIs or deaths.


CONCLUSIONS
An intracoronary flush cocktail containing a combination of two potent arteriolar vasodilators, nicardipine and adenosine, appears to be a safe and effective regimen for minimizing no-reflow events and periprocedural myonecrosis during RA.
Fischell
Tim A
TA
Michigan State University, Heart Institute at Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49001, USA. taf1@net-link.net
Haller
Scott
S
Pulukurthy
Satyavardham
S
Virk
Imran S
IS
D000241:Adenosine / Q000008:administration & dosage*; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D017225:Atherectomy, Coronary / Q000009:adverse effects*; D015415:Biomarkers / Q000097:blood; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000187:drug effects; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D003402:Creatine Kinase / Q000097:blood; D052279:Creatine Kinase, MB Form / Q000097:blood; D004338:Drug Combinations; D005260:Female; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000201:enzymology / Q000473:pathology; D009336:Necrosis; D009529:Nicardipine / Q000008:administration & dosage*; D005996:Nitroglycerin / Q000008:administration & dosage; D054318:No-Reflow Phenomenon / Q000209:etiology / Q000473:pathology / Q000503:physiopathology / Q000517:prevention & control*; D011446:Prospective Studies; D012042:Registries; D013997:Time Factors; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage*
D000925:Anticoagulants; D015415:Biomarkers; D004338:Drug Combinations; D014665:Vasodilator Agents; D006493:Heparin; D009529:Nicardipine; D003402:Creatine Kinase; D052279:Creatine Kinase, MB Form; D005996:Nitroglycerin; D000241:Adenosine